WQ0013852_Final Permit_20091029

„AF'!}
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Qual ty
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
October 29, 2009
EVANGELINE GERWIG DEACON TRUST
C/o DANIEL J. DEACON
458 EAGLE. DRIVE
CHAPEL HILL, NORTH CAROLINA 27517
Dear Mr. Deacon:
Dee Freeman
Secretary-
Subject:
ecretary
subject: Permit No. WQ0013852
Evangeline Gerwig Deacon
Trust SFR
Single -Family Residence
Wastewater Irrigation System
Chatham County
In accordance with your permit major modification request received August 19, 2009, and
subsequent additional information received October 6, 2009 and October 27, 2009, we are forwarding
herewith Permit No. WQ0013852, dated October 29, 2009, to the Evangeline Gerwig Deacon Trust for
the construction and operation of the approved modifications and continued operation of the existing
subject single-family residence wastewater treatment and irrigation facilities.
The following modifications to the subject permit are as follows: 10,240 square foot ff 2)
expansion of the existing spray field, thus increasing the total area to 20,637 ft'; a precipitation/soil
moisture sensor; and audible/visual high-water alarms for the existing 3,000 gallon storage/pump tank.
This permit shall be effective from the date of issuance until October 31, 2015, shall void Permit
No. WQ0013852 issued November 19, 2007 and shall be subject to the conditions and limitations as
specified therein. An extension shall be requested at least six months prior to the expiration of this
permit. Upon receipt of the request, the Commission will review the adequacy of the facility described
therein and, if warranted, will extend the permLit for such period of time and under such conditions and
limitations as it may deem appropriate.
Please pay particular attention to the operation and maintenance requirements listed in Section III
for they may differ from the previous permit issuance. Failure to establish an adequate system for
collecting and maintaining the required operational information shall result in future compliance
problems.
AQUIFEP, PRaTECTM S_CTIOP
153Y b ail Service C��te`. Ral . :::r, - Cary —, M95-1635
LC-_atir 2728 Ckaitai Boufevzi�. Rz--^`.. t•:�r” Ca; 7ifrla 27c:;
Phone: 919-73"1-3221 i FAX t 919-715-0588; FAX 2: 919-715.8048 ,Customer Sem: e: 1-877$2::6740
irteme`: a vww.ncwaterquality.org
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I�of 1[_n aj-oRna
,-Natimally

Mr. Daniel J. Deacon
October 29, 2009
Page 2 of 2
Please note the following conditions are specific to this permit and warrant your attention:
➢ Condition I.1. — This condition requires the Permittee to modify the existing 3,000 gallon
storage/pump tank to include an alarm float and associated audible/visual high-water alarms
prior to operation of the modified facilities.
➢ Condition 1.2. — This condition requires the Permittee to record the attached signed Setback
Waiver Form with the Chatham County Register of Deeds within 90 days of permit issuance.
If any parts, requirements or limitations contained in this permit are unacceptable, the Permittee
has the right to request an adjudicatory hearing upon written request within 30 days following receipt of
this permit. This request shall be in the form of a written petition, conforming to Chapter 150B of the
North Carolina General Statutes, and filed with the Office of Administrative Hearings at 6714 Mail
Service Center, Raleigh, NC 27699-6714. Unless such demands are made, this permit shall be final and
binding.
One set of approved plans and specifications is being forwarded to you. If you need additional
information concerning this matter, please contact Nathaniel Thornburg at [phone] or
nathaniel.thornbur�-TL�ncdenr.gov.
Sincerely,
01�U
V- . oleen H. Sullins
cc: Chatham County Health Department
Raleigh Regional Office, Aquifer Protection Section
Jerry T. Dalton, PE — Dalton Engineering and Associates, PA
Technical Assistance and Certification Unit
Permit File WQ0013852
Notebook File WQ0013852

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH
SINGLE-FAMILY RESIDENCE WASTEWATER IRRIGATION SYSTEM PERMIT
In accordance with the provisions of Article 21 of Chapter 143, General Statutes of North Carolina as
amended, and other applicable Laws, Rules and Regulations
PERMISSION IS HEREBY GRANTED TO
Evangeline Gerwig Deacon Trust
Chatham County
FOR THE
operation of a 480 gallon per day (GPD) single-family residence wastewater treatment and irrigation
facility consisting of:
the continued operation of: a 1,000 gallon baffled septic tank; a 1,200 gallon baffled sand filter pump tank
with a 12 gallon per minute (GPM) pump; a 144 square foot (ft) surface sand falter in dual parallel tanks;
a tablet chlorinator; a 3,000 gallon storage/pump tank with a 20 GPM pump; a 10,397 ft'` spray irrigation
area; and all associated alarms, piping, valves, controls and appurtenances; and .
the construction and operation of: an additional 10,240 R2 of spray irrigation area, increasing the total
spray irrigation area to 20,637 ft'; a precipitationisoil moisture sensor; and audible/visual high-water
alarms for the existing 3,000 gallon storage/pump tank;
to serve the Evangeline Gerwig Deacon Trust SFR (456 Eagle Drive), with no discharge of wastes to
surface waters, pursuant to the application received August 19, 2009, and subsequent additional
information received by the Division of Water Quality, and in conformity with the project plans,
specifications, and other supporting data subsequently filed and approved by the Department of
Environment and Natural Resources and considered a part of this permit.
This permit shall be effective from the date of issuance until October 31, 2015, shall void Permit No.
WQ0013852 issued November 19, 2007, and shall be subject to the following specified conditions and
limitations:
WQ0013852 Version 2.1 Shell Version 091027 Page 1 of 9

I. SCHEDULES
1. Prior to operation of the modified permitted facilities, the Permittee shall install an alarm float in the
3,000 gallon storage/pump tank. This float shall be connected to an audible/visual high-water alarm
that shall be external to any structure. The Engineering Certification shall serve as evidence that this
condition has been met.
2. Within 90 days of permit issuance, the Permittee shall record the following setback waiver (see
attached) in the Chatham County Register of Deeds.
The Permittee shall submit copies of the recorded setback waiver to the Division of Water Quality,
Aquifer Protection Section, 1636 Mail Service Center, Raleigh, NC 27699-1636.
3. In accordance with 15A NCAC 02T .0 116, upon completion of construction and prior to operation of
the permitted facility's modifications, a certification (attached) shall be submitted from a licensed
North Carolina Professional Engineer certifying that the permitted facility's modifications have been
installed in accordance with this permit, Division approved plans and specifications, and other
supporting documentation, including the location of all monitoring wells as applicable. If this project
is to be completed in phases and partially certified, the Permittee shall retain the responsibility to
track further construction a roved under the same ermit - and shall provide a final certificate of
completion once the entire project has been completed. Mail the Certification to the Division of
Water Quality, Aquifer Protection Section, 1636 Mail Service Center, Raleigh, NC 27699-1636.
4. The Raleigh Regional Office, telephone number [phone], shall be notified at least 48 hours in
advance (excluding weekends and holidays) of operation of the installed modified facilities such that
an in-place inspection can be made. Notification to the Aquifer Protection Section's regional
supervisor shall be made from 8:00 a.m. until 5:00 p.m, on Monday through Friday, excluding State
Holidays.
No later than six months prior to the expiration of this permit, the Permittee shall request renewal of
this permit on official Division forms. Upon receipt of the request, the Division will review the
adequacy of the facilities described therein, and if warranted, will renew the permit for such period of
time and under such conditions and limitations as it may deem appropriate. Please note Rule 15A
NCAC 02T .0105(d) requires an updated site map to be submitted with the permit renewal
application.
6. In accordance with 15A NCAC 02T .0607, if a public or community sewage system is or becomes
available, the subject single-family residence wastewater treatment and irrigation facilities shall be
closed and all wastewater shall be discharged into the public or community sewage system within 180
days of its availability. Prior to the initiation of these connection activities, appropriate Division
approval shall be received.
WQQ013852 Version 2.1 Shell Version 091027 Page 2 of 8
PIN
Owner
Setback
9796-61-4828
Evangeline Gerwig Deacon Trust
Irrigate within 50 ft of the property line
The Permittee shall submit copies of the recorded setback waiver to the Division of Water Quality,
Aquifer Protection Section, 1636 Mail Service Center, Raleigh, NC 27699-1636.
3. In accordance with 15A NCAC 02T .0 116, upon completion of construction and prior to operation of
the permitted facility's modifications, a certification (attached) shall be submitted from a licensed
North Carolina Professional Engineer certifying that the permitted facility's modifications have been
installed in accordance with this permit, Division approved plans and specifications, and other
supporting documentation, including the location of all monitoring wells as applicable. If this project
is to be completed in phases and partially certified, the Permittee shall retain the responsibility to
track further construction a roved under the same ermit - and shall provide a final certificate of
completion once the entire project has been completed. Mail the Certification to the Division of
Water Quality, Aquifer Protection Section, 1636 Mail Service Center, Raleigh, NC 27699-1636.
4. The Raleigh Regional Office, telephone number [phone], shall be notified at least 48 hours in
advance (excluding weekends and holidays) of operation of the installed modified facilities such that
an in-place inspection can be made. Notification to the Aquifer Protection Section's regional
supervisor shall be made from 8:00 a.m. until 5:00 p.m, on Monday through Friday, excluding State
Holidays.
No later than six months prior to the expiration of this permit, the Permittee shall request renewal of
this permit on official Division forms. Upon receipt of the request, the Division will review the
adequacy of the facilities described therein, and if warranted, will renew the permit for such period of
time and under such conditions and limitations as it may deem appropriate. Please note Rule 15A
NCAC 02T .0105(d) requires an updated site map to be submitted with the permit renewal
application.
6. In accordance with 15A NCAC 02T .0607, if a public or community sewage system is or becomes
available, the subject single-family residence wastewater treatment and irrigation facilities shall be
closed and all wastewater shall be discharged into the public or community sewage system within 180
days of its availability. Prior to the initiation of these connection activities, appropriate Division
approval shall be received.
WQQ013852 Version 2.1 Shell Version 091027 Page 2 of 8

II.PERFORMANCE STANDARDS
The subject non -discharge facilities shall be effectively maintained and operated at all times so there
is no discharge to surface waters, nor any contravention of groundwater or surface water standards.
In the event the facilities fail to perform satisfactorily, including the creation of nuisance conditions
due to improper operation and maintenance, or failure of the irrigation areas to adequately assimilate
the effluent, the Permittee shall take immediate corrective actions including Division required actions,
such as the construction of additional or replacement wastewater treatment or disposal facilities.
2. This permit shall not relieve the Permittee of their responsibility for damages to groundwater or
surface water resulting from the operation of this facility.
Application rates, whether hydraulic, nutrient or other pollutant, shall not exceed those specified in
the following table:
TABLE 1— APPLICATION LIMITATIONS
Field
Parameter
Hourly Rate
Yearly Max
Units
1
Application Surface Irrigation — 01284
0.4
13.62
Inches
4. The subject facility has been approved to land apply wastewater effluent on the following fields:
TABLE 2 — IRRIGATION AREA INFORMATION
Field
Owner
County
Latitude
Longitude
Net
Dominant
Acreage
Soil Series
I
Evangeline GerMg Deacon Trust
Chatham
350 50'34"
-790 00' 35"
0.47
Creedmoor
5. The Operation and Maintenance Agreement (attached) between the Permittee and the Division of
Water Quality is incorporated herein by reference and shall be a condition of this permit.
Noncompliance with the terms of the Operation and Maintenance Agreement shall subject the
Permittee to all sanctions provided by North Carolina General Statutes §143-215.6A to §143-215.6C
for violation of or failure to act in accordance with the terms and conditions of this permit.
6. The irrigation system shall be connected to a rain or moisture sensor, which shall indicate when
effluent application is not appropriate in accordance with Conditions IIIA. and 111.5. of this permit.
7. In accordance with 15A NCAC 02L .0107(i), the compliance boundary is established at the property
boundary. Any exceedance of standards at the compliance boundary shall require action in
accordance with 15A NCAC 02L .0106.
8. In accordance with 15A NCAC 02L .0108, the review boundary is established midway between the
compliance boundary and the effluent disposal area. Any exceedance of groundwater standards at the
review boundary shall require action in accordance with 15A NCAC 02L .0106.
9. The Permittee shall apply for a permit modification to establish a new compliance boundary prior to
any sale or transfer of property affecting a compliance boundary.
WQ0013852 Version 2.l Shell Version 091027 Page 3 of 8

10. The facilities permitted herein shall be constructed according to the following setbacks:
a. The setbacks for irrigation sites (i.e., eastern portion of spray field) permitted prior to September
1, 2006 shall be as follows (all distances in feet):
i. Any habitable residence or place of public assembly under separate ownership: 400
ii. Surface waters:
100
iii. Any well with exception of monitoring wells:
100
iv. Any property line:
150
v. Any swimming pool:
100
vi. Public right of way:
50
1 Per the setback waiver recorded in the Chatham County Register of Deeds (Book 728, Page
682), setbacks to property lines have been reduced for the following:
PIN
Owner
Setback
9796-71-1834
Daniel & Elizabeth Deacon
0 feet
b. The setbacks for irrigation sites (i.e., western portion of spray field) permitted after September 1,
2006 shall be as follows (all distances in feet):
i. Any habitable residence or place of public assembly under separate ownership: 400
ii. Any habitable residence or place of public assembly owned by the Permittee:
200
iii. Any private or public water supply source:
100
iv. Surface waters:
100
v. Groundwater lowering ditches:
100
vi. Surface water diversions:
25
vii. Any well with exception of monitoring wells:
100
viii. Any property line:
150 1'
ix. Top of slope of embankments or cuts of two feet or more in vertical height:
15
x. Any water line from a disposal system:
10
xi. Subsurface groundwater lowering drainage systems:
100
xii. Any swimming pool:
100
xiii. Public right of way:
50
xiv. Nitrification field:
20
xv. Any building foundation or basement:
15
See footnote above.
Per the setback waiver to be recorded in the Chatham County Register of Deeds (See Condition
1.2.), setbacks to property lines have been reduced for the following:
PIN
Owner
Setback
9796-61-4828
Evangeline Get -wig Deacon Trust
50 feet
c. The setbacks for storage and treatment units permitted prior to September 1, 2006 shall be as
follows (all distances in feet):
i. Any well with exception of monitoring wells:
ii. Any property line:
100
50
WQ0013852 Version 2.1 Shell Version 0910727 Page 4 of 9

II1. OPERATION AND MAINTENANCE REQUIREMENTS
The facilities shall be properly maintained and operated at all times. The facilities shall be effectively
maintained and operated as a non -discharge system to prevent the discharge of any wastewater
resulting from the operation of this facility. The Permittee shall maintain an Operation and
Maintenance Plan pursuant to 15A NCAC 02T .0604(f).
Upon the Water Pollution Control System Operators Certification Commission's (WPCSOCC)
classification of the subject non -discharge facilities, in accordance with 15A NCAC 08G .0200 the
Permittee shall designate and employ a certified operator in responsible charge (ORC) and one or
more certified operator(s) as back-up ORC(s). The ORC or their back-up shall visit the facilities in
accordance with 15A NCAC 08G ,0200, and shall comply with all other conditions specified in the
previously cited rules.
3. A suitable year round vegetative cover shall be maintained at all times, such that crop health is
optimized, allows for even distribution of effluent and allows inspection of the irrigation system_
4. Adequate measures shall be taken to prevent effluent ponding in or runoff from the irrigation sites
listed in Table 2 of Condition TIA.
5. irrigation shall not be performed during inclement weather or when the ground is in a condition that
will cause ponding or runoff,
6. Only effluent from the Evangeline Gerwig Deacon Trust SFR shall be irrigated on the sites listed in
Table 2 of Condition IIA.
7. No automobiles or machinery shall be allowed on the irrigation sites except during equipment
installation or while maintenance is being performed.
8. Public access to the irrigation sites and wastewater treatment facilities shall be prohibited. Fencing
shall be provided to prevent access to the irrigation site (minimum 2 -strand wire) and treatment units
shall be secured with locks on all tank accesses and control panels.
The residuals generated from the wastewater treatment facilities shall be disposed or utilized in
accordance with 15A NCAC 02T .1100.
10. Diversion or bypassing of untreated or partially treated wastewater from the treatment facilities is
prohibited.
11. Pump/dosing tanks shall have audible and visual alarms external to any structure.
WQ0013852 Version 2.1 Shell Version 091027 Page 5 of 8

IV. MONITORING AND REPORTING REQUIREMENTS
1. Any Division required monitoring (including groundwater, plant tissue, soil and surface water
analyses) necessary to ensure groundwater and surface water protection shall be established, and an
acceptable sampling reporting schedule shall be followed.
2. Noncompliance Notification:
The Permittee shall report by telephone to the Raleigh Regional Office, telephone number (919) 791-
4200, as soon as possible, but in no case more than 24 hours, or on the next working day following
the occurrence or first knowledge of the occurrence of any of the following:
a. Any process unit failure (e.g., mechanical, electrical, etc.), due to known or unknown reasons,
rendering the facility incapable of adequate wastewater treatment.
b. Any facility failure resulting in a by-pass directly to receiving surface waters.
c. Any time self-monitoring indicates the facility has gone out of compliance with its permit
limitations.
d. Ponding in or runoff from the irrigation sites.
Any emergency requiring immediate reporting (e.g., discharges to surface waters, imminent failure of
a storage structure, etc.) outside normal business hours shall be reported to the Division's Emergency
Response personnel at telephone number [phone], [phone], or [phone].
Persons reporting such occurrences by telephone shall also file a written report in letter form within
five days following first knowledge of the occurrence. This report shall outline the actions taken or
proposed to be taken to ensure the problem does not recur.
V. INSPECTIONS
1. The Permittee shall provide adequate inspection and maintenance to ensure proper operation of the
wastewater treatment and irrigation facilities.
2. The Permittee or their designee shall inspect the wastewater treatment and irrigation facilities to
prevent malfunctions, facility deterioration and operator errors resulting in discharges, which may
cause the release of wastes to the environment, a threat to human health or a public nuisance. The
Permittee shall maintain an inspection log that includes, at a minimum, the date and time of
inspection, observations made, and any maintenance, repairs, or corrective actions taken. The
Permittee shall maintain this inspection log for a period of five years from the date of the inspection,
and this log shall be made available to the Division upon request.
3. Any duly authorized Division representative may, upon presentation of credentials, enter and inspect
any property, premises or place on or related to the wastewater treatment and irrigation facilities
permitted herein at any reasonable time for the purpose of determining compliance with this permit;
may inspect or copy any records required to be maintained under the terms and conditions of this
permit, and may collect groundwater, surface water or leachate samples.
WQ0013852 Version 2.1 Sbell Version 091027 Page 6 of 8

l
V1. GENERAL CONDITIONS
1. Failure to comply with the conditions and limitations contained herein may subject the Permittee to
an enforcement action by the Division in accordance with North Carolina General Statutes 143-
215.6A to 143-215.6C.
2. This permit shall become voidable if the permitted facilities are not constructed in accordance with
the conditions of this permit, the Division approved plans and specifications, and other supporting
documentation.
3. This permit is effective only with respect to the nature and volume of wastes described in the permit
application, Division approved plans and specifications, and other supporting documentation. No
variances to applicable rules governing the construction or operation of the permitted facilities are
granted, unless specifically requested and approved in this permit pursuant to 15A NCAC 02T
.0105(n).
4. The issuance of this permit does not exempt the Permittee from complying with any and all statutes,
rules, regulations, or ordinances, which may be imposed by other jurisdictional government agencies
(e.g., local, state, and federal). Of particular concern to the Division are applicable river buffer rules
in 15A NCAC 02B .0200; erosion and sedimentation control requirements in 15A NCAC Chapter 4
and under the Division's General Permit NCGO10000; any requirements pertaining to wetlands under
15A NCAC 02B .0200 and 02H .0500; and documentation of compliance with Article 21 Part 6 of
Chapter 143 of the General Statutes.
5. In the event the permitted facilities change ownership or the Permittee changes their name, a formal
permit modification request shall be submitted to the Division. This request shall be made on official
Division forms, and shall include appropriate property ownership documentation and other supporting
documentation as necessary. The Permittee of record shall remain fully responsible for maintaining
and operating the facilities permitted herein until a permit is issued to the new owner.
6, The Permittee shall retain a set of Division approved plans and specifications for the life of the
facilities permitted herein.
7. The Permittee shall maintain this permit until all permitted facilities herein are properly closed or
permitted under another permit issued by the appropriate permitting authority pursuant to 15A NCAC
02T.01050).
8. This permit is subject to revocation or unilateral modification upon 60 days notice frons the Division
Director, in whole or part for the requirements listed in 15A NCAC 02T .0110.
9. Unless the Division Director grants a variance, expansion of the permitted facilities contained herein
shall not be granted if the Permittee exemplifies any of the criteria in 15A NCAC 02T .0120(b).
10. The Permittee shall pay the annual fee within 30 days after being billed by the Division. Failure to
pay the annual fee accordingly shall be cause for the Division to revoke this permit pursuant to 15A
NCAC 02T .0105(e)(3).
Permit issued this the 29`h day of October 2009
NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
;IColeen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission
Permit Number WQ0013852
WQ0013852 Version 2.1 Shell Version 091027 Page 7 of 8

Permit No. WQ0013852 Single -Family Residence Wastewater Irrigation System
Evangeline Gerwig Deacon Trust October 29, 2009
Evangeline Gerwig Deacon Trust SFR Chatham County
ENGINEERING CERTIFICATION
❑ Partial ❑ Final
In accordance with 15A NCAC 02T .0116, 1,_ ,
as a duly registered Professional Engineer in the State of North Carolina, having the Permittee's
authorization to ❑ periodically ❑ weekly ❑ fully observe the construction of the permitted facility,
hereby state to the best of my abilities that due care and diligence was used in the observation of the
construction, such that the facility was built within substantial compliance and intent of this permit, the
Division approved plans and specifications, and other supporting documentation.
❑ Any variation to this permit, the Division approved plans and specifications, and other supporting
documentation has been documented in the attached as -built drawings, and shall serve as the
Permittee's minor modification request to amend the permit accordingly.
Provide a brief narrative description of any variations:
NC PE Seal, Signature & Date
THE COMPLETED ENGINEERING CERTIFICATION, INCLUDING ALL SUPPORTING
INFORMATION AND MATERIALS, SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
LAND APPLICATION UNIT
By U.S. Postal Service: By Courier/Special Delivery:
1636 MAIL SERVICE CENTER 2728 CAPITAL BOULEVARD
RALEIGH, NORTH CAROLINA 27699-1636 RALEIGH, NORTH CAROLINA 27604
WQ0013852 Version 2.1 Sheli Version 091027 Page 8 of 8
I

RECEIVED 1 DENR I DWQ
OPERATION AND MAINTENANCE AGREEMENfAQUIFFP-FPOTFrTlf)N SFCT1%
SINGLE FAMILY RESIDENCE SURFACE IRRIGATION SYSTEAVG 19 2009
DIVISION OF WATER QUALITY
Property Owner(s) (as appearing on the property deed): t E'r MA f �LSJ:—
Mailing Address:
. ?L5�1>
Facility Address (if different than above): Ll - x_19 4 A( y'JC,2C
Disposal Method: 0L- RAY IRRIGATION ❑ DRIP IRRIGATION (Check One)
County: C/ Permit No. 222135 —Z—
IfWe agree to operate and maintain the wastewater treatment system as follows:
1. The Permittee is responsible for the operation and maintenance of the entire treatment and disposal
system including, but not limited to, the following items:
a. The septic tank shall be checked annually and pumped out as needed. The effluent filter shall be
checked and cleaned at the same frequency of the septic tank.
b. The sand filter surface shall be raked and leveled every six (6) months and any vegetative growth
shall be removed by hand [accessible sand filters only).
c. �Checkk 0 e:
Ids The tablet chlorinator shall be checked every week. Tablets shall be added so as to provide
proper chlorination.
❑ The ultraviolet disinfection unit shall be checked every week. The lamp shall be cleaned
and/or replaced to ensure proper disinfection.
d. The storage, pump, and alarm systems shall be inspected monthly. The scum layer shall be
removed at the same time interval as the septic tank is pumped out.
e. The irrigation system shall be inspected monthly to make certain of proper operation, that
vegetative growth does not interfere with the system inspection or operation, that the soil is
assimilating the disposed treated wastewater with no surface runoff, and that no objectionable
odors are being generated.
2. Failure of the Permittee to properly operate this system is subject to a penalty up to $25,000 per day.
3. Failure to meet the permit conditions or violation of the State's surface or groundwater regulations
will require evacuating the dwelling and may void the permit.
NOTE: All persons (owners) appearing on the legally registered property deed must sign this O&M
Agreement
I/We understand the above requnts and agree ese erms as part of the issued permit.
Owner(s) Signature(s): Date:
Owner(5) Signature(s): Date:
SFR O&M (version 07107)

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Latitude: 35° 50'34"
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State of North CaroUiaa
D"artment of lEnvie3 an=ent and Natural ltftources
SETBACK WArVER FORM
(THISFORM W Y M F°fitYTOCOPiED FOR USE AS"OR(GINAL)
The Division of Water Quality will not consider this attachment forra to 6e complete unless an the
Imtnictiiatts am Ulowed. Failure to follow the instructiow or to submitatl of the required items
w0i kod to additional procvsing and review time for the appIcation.
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Do not submit th6 M*ochrateat Perm for revier wi4bovi a for iOg Lood Appt. me ion Unit
sr�i�ttit?tt fpm..
✓ Any changes to t�i:s stta ,unt form vAll fesWt its tho appilcation package being ratiurned.
Any anter S,�tberks ruquircd by 15A, KCAC2T ,4546 and .0606 athu tirar those refereneed below, c� I
6e waived 42zrnt l *XeCU iO� of this fa=,
V A. oopY of the cm*kxed and appnspriatety exocut*d form rrwst b~ provided to dre Propsxry ownrx.
15A NCAC ZT .05 a) 050", smd W6(a)
The undtr dg property aw,apks) hereby pet it:
Applicant's name:
Complete w6bug addsr;ss of appUc�rav
City: � _ stag: -� �-�
4.4
Telepbone aomber: (Ma} nxu : (2�b a E
hereinafter referred to as tate Peritttee, to Geek all that apply);
Frtigate watstewater witWu+:3, feet of the prop" line., . •,,
Q Irrigate -wastewater wit%n feet d the iticvtified reAdenee,
[] Crat Arnd wastewater tmaUumt units within _ feet of the: property tine;
as shown on the attached map mW 3o ed at the follo ing- :.
Locatiauaddress of property- Loa It -6
t_" Zs' ! ,
City-_..� ��;rP,l�lfr�.r�..�_._ State: i� �, _ . -�-----
I cu&y that I ant a deeded pmpnny Qwutger al' Abovt!-mfertrtcrd property and am authaxiZed to make
deicisiorta regtrding t#3s pmpWy on behalf of other ceded property ow=s. Puerdte> more, I cattify
ibat t have read W ondcratand this Agmenrent and do h teby gx=tt pzrmission to the Permittee to
xmpled wastewraier or ecrrtstretct w'aawwa= tmatruant units a3 speci£md hen. I Wag agM.Gi�ec
t;Drnz issuance 4f 5 1C17i2tt by i%te Di Vts31 fqC ill{'e_Ytiw1iYL'Li Viii 3{sct]rd ritiS
waiter fansr docu emtstsan of
0913_
Propwy awnl�x(s) R=e(s):
sign [��nr r, .3 ... �. e�,+r �� �C Date: J[ - C
signat=-, 1]atc:
PORM: SWE 10-T
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